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OK, we should be live. Hello, everyone and good evening, welcome to our webinar about building your portfolio today. Um Could we just indicate in the chat if you can hear me and if you can see our screen, I'll just wait for a few moments if someone could just let us know whether you can hear us and see us if you can hear us and see us. If someone can just message in the group chat and then we'll be ready to start hoping you can hear and see us. They all just great. There we go see him here. Well, perfect. So welcome everyone. Good evening and thank you so much for joining us today. Um Firstly, I'd like to introduce Dan. This is Dan from the BMA. He's gonna be telling us a bit more about the BMA and what they um offer. Um especially as there's gonna be a lot of new graduates and final years that are gonna be on this webinar. Um And then we're going to have Doctor Jihad Osman, he's going to be running our webinar today about quips quality improvement projects. Um So we're gonna learn a bit more about them, how they're run and why they're so important for our portfolios. So, thank you so much, Dan. I'm gonna hand over to you. Thanks a moment. Yeah, I'll be super, super duper quick. I'll just put that on the chart uh to make this work a bit smooth. I might just turn my camera off. Sorry cos I'm I'm looking at this screen here. Um ok, so first things first. Um sorry for the big letters on the screen. Um quite overwhelming. Um but yeah, you guys, er, you might not know this but you can actually be um in membership of, of the BMA. Um right now, even though you're, you're based out based on Bulgaria, of course, um what we need to do is is follow that QR code. Um and there you go, this, this sort of explains it a bit better follow that QR code on the screen. Um, click on, I'm a UK medical student and then complete the questions as you go. Uh and, and there'll be an option um as the medical schools overseas Bulgaria. Um and then it'll come up um and you just, you just go through as usual if you join today. Um This is just a bit of a special cos I'm because I'm seeing you guys, um you'll get your first month of membership free and you'll get a, a 10 lb Amazon voucher. So to get the Amazon voucher, um just after you've joined, if you drop me an email, um, detail at bma.org dot UK um, with your BM aid, I'll get that e email, I'll get that, um, Amazon voucher sent out to you as well. Um, so yeah, it's, it's about saving about 13 lb 50 10 lb Amazon voucher plus 1 lb free. Um, so it equates to getting about four months of BMA membership free and if you guys are close to, er, to graduating, um, and obviously starting your FWA F one. it's a pretty, pretty good deal. Um, and yeah, you only sort of get this if you see me. So, um, take advantage of it, get in touch with me if you're unsure whether you're a membership or not already. Um, but yeah, so, um, first things first. Oh, I think I'm at the very end of my presentation. Rather, the very start. So, but there we go first things first. So, yeah, I'm done. I work in BMA. Um, I'm, I'm based in Central London. Um, if, if you guys do end up working in any of the London trust, you'll, you'll see me um, around a bit. Um, so, yeah, so what do we do? So we, we're obviously the trade union and professional association with doctors and Measures, um, in the UK and also yourselves. Um, three ways of looking at how we support, um, you guys um, individually locally and nationally. So obviously on an individual basis, um, you can use sort of all the individual tools and stuff. So stuff like B MJ learning B MJ. Um also sort of nonclinical stuff. So when you guys start and you have um pay issues, contractual issues, you can come to us and, and we can sort of help with those. Um on a local level is your a group of F ones and you're also having similar issues. We've got people on the ground who can help, who can help you with contractual issues and whatnot. Then obviously on, on a national basis, we have things like the pay restoration campaign. So I'll get onto that, but essentially your pay has gone up to about 20 25% in the last two years. Thanks to the work of the BMA and obviously members and all the strike stuff that has been going on with potential more to come, things that you can use right now right away. Um You've got full access to our BMA library, everything's online. So location wise, it's not not an issue. Um You can log in, you can use all of our tools. Um Clinical T is a clinical key, sorry is a point of care tool, er, which you can use as well. So again, you'll get a full login to that, no paywalls or anything. Um It's, it's a, it's a third party um company, but we've bought access to it. So all of our members will get full access to that. Um We've got a specialty explorator, so possibly early. But if you're thinking about your specialty already, um you can use the specialty Explorator es essentially an, an online psychometric test takes about 20 minutes to complete. It'll ask all sorts of work life balance questions. Um And then at the end, it will give you a breakdown of what specialties will suit you according to the answer you've given. Um got full access to all of our BBM J learning tools. Um So yeah, really good for revision um for passing exams and whatnot. So make the most of those um B MJ learning. So these are just some topics for, for incoming F ones. So not only do we do sort of clinical stuff, but we also have loads of nonclinical um things as well which you might, you might find um useful. Um So yeah, it's just about preparing yourself for, for F one as well as, as well as obviously preparing for exams and whatnot now. So like I said, you get access to the B MJ. Um you'll have because, because we obviously can't deliver it to you guys, you'll have the online subscription. Um So you can have the app and you'll, you'll be able to read all the latest issues and older issues um as and when they come out as of last week, um the B MJ has moved after God knows how many years, probably 30 years to um from weekly to Fortnite, you say it's issued every fortnight now. Not, not every week. Ok. So big, big, big thing to, to talk about, um, mention it at the start. Um, this is, this is basic pay. So this is before any sort of additional, um, additional payments, additional hours, you know, working weekends or whatever. Um, but uh, also if you're in London, not that it's any good, um, er, London waiting is obviously not included in this either. Um But yeah, as you can see where 2022 2023 F one pay was um before the start of the pay restoration campaign. So in the last two years, 28,384 it's now gone up to 36 616 as of today. So that's an increase of 24.61%. Um which is incredible. Obviously, restoration is the, is the, is what we want overall. So we're not necessarily saying that we're stopping there. Um But just, um it's just worth drawing attention to because you guys obviously stand to gain from this as, as incoming ones. Um So yeah, you can see down as you go down the list as well, sort of the uplift on the 2223 scale. Um It's around about 2021 22% across the board. Um So, yeah, so hopefully if nothing else that, that's, that um incentivize you to want to be part of the BMA and what we do. I don't know how I jumped back so far. Um, so yeah, we, we advised our, our membership back in summer last year to, to accept this me, er, this, this deal, um, as and when it came out, um, with a plan obviously for, for building on top of that. Um, sadly this is, this is recent news in the last couple of weeks. Um, The government has recommended to the DDR B. So doctors and dentist review body, um only a 2.8% pay rise for this year, which obviously is not in line with pay restoration, which ultimately is what we still want. Um So things are, oh God, this keeps jumping on. Um So things are, hm Here we go. Um So things are heating up a little bit. There's, there's talks possibly of, of rebooting numbers again. Um And then obviously further industrial action, but that's no, nothing's concrete yet, but obviously, it will affect you guys um as F ones if we were to ballot or if we were to, to decide to do to do this. Um You're sort of looking at April, we would have a six month man mandate of striking which would sort of take, take us through kind of to when you guys start as F ones. Um So yes, it's possible that this wrong was on. Obviously, only members of the BMA get a say in this and get a say on, on Barts and whatnot. So even even more reason now to, to be involved, um just a few things when you do start work, obviously, everything non clinical you can come to us for and we can help. Sometimes we get a bit of confusion with, with companies like MDU mps, but they're um they're indemnity companies. So, so if you were to cut a patient, it's mdu mps or indemnity company, go to everything else. You pay contracts. Um You can come to us uh uh and we can help you. Uh That's it. I'm trying to, trying to be as quick as possible. Sorry. But um yeah, if, if you think about joining do take advantage of this. If you go on our website and join you don't, you don't get anything like a like a month free or anything. So, so yeah, it's just because I've come along today. So you get the first month free. Um If you use that QR code or the link I put in the chat and also uh you get an Amazon voucher. So just drop me an email after you join and I'll, I'll get that sorted for you. That's it. Try to be as quick as possible. Um Yeah, thanks. Thanks for listening and enjoy the session. I'll hand you back. Thank you very much, Daniel. Um Can I just um confirm that you guys can hear me? Someone could just pop a message in the chat just waiting for that. Can you guys hear me? Perfect. Fantastic. Yeah, so thank you, Dan. Um I can confirm the BMA is incredible um as an I MG they, they provide us with so, so much support and um I can't recommend them enough. Um So hi everyone. Um My name is Giard. I'm a currently an FY two here in Liverpool. Um and I'm doing this session today on quality improvement projects also known as uh Q I PS. And sometimes you might refer to them as Qis. Um The reason I'm doing this session today is because when I graduated from Sophia, which was in February 2023 I had no idea what AQ I was and I definitely had no idea of how much significant in weight um they put onto it here in, in the NHS. So, um for you guys who have either recently graduated or are coming towards the end of your, um, studying, studying period. Um I think it would be a good idea to just touch uh touch base with what AQ I is and um make sure that you guys aren't behind any of the other graduates who will have potentially started completed or, or just at least aware of what AQ I is soap in this session. Um I hope that we're gonna explain what is AQ I and I also want to really push why it's important. Um I want to also discuss what the difference between an audit and AQ I is. It's a very, very common misconception. You'll often hear the words used interchangeably, but they are not the same thing. And there is a very clear defined difference. Um It's also a common interview question that they ask IM GS of what's the difference between an audit versus AQ I. So, um that's something that I really want you guys to be aware of. want to briefly go over. How can you guys pick the right project? What is the right project? Um And then very, very briefly gonna talk about the theoretical background of qis understanding the psychology of it and then going into more details of what makes an acceptable Q I and how can you appropriately and properly presented? Um Now it's a lot of information um just to put it into context when I was in F one, we had a course that pretty much lasted six hours explaining, we're going to try and hopefully do it an hour. We are just going to touch base. There will be some of the finer details left out of this presentation. However, at the end, I'm gonna give you guys some details if you are deciding to, to pursue your own Q I who you can contact. And um here at tips. So tips is a uh a regional um or peer led organization that supports doctors in this region with their own qis. However, if you guys contact us. Um We will definitely um support you guys. Let me just make sure this is a text. OK. Fantastic. So what is Q I now defining quality improvement is notoriously quite difficult. Um Different people have different definitions for it, but broadly speaking, it's a project created with the intention of producing better patient experiences and better outcomes achieved through changing provider and organization behaviors. And this change has to be a systemic change which can be measured. So, in order to do that, you need to understand that the environment that we work in is quite complex. As I said, we need to then create and apply a systemic approach. And we also need to be able to demonstrate through testing and implementing those changes in real time that we're actually making an improvement. The Royal College of General Practitioners has their own definition, which I've listed here. Um which is that Q I PS are the focus on improving service delivery and patient outcomes to achieve specific goals by designing and implementing a change, followed by measured evaluation. So I know that's a lot of um almost verbal diarrhea. But basically what we're doing is we are trying to identify a problem and then we want to think about what improvement we can add and then we need to measure it and prove that whatever we've implemented is actually making an improvement. Now again, I've just put the goal of AQ IP is to improve the quality of care by identifying areas of concerns and making small changes. And that's another thing AQ I doesn't have to be a massive, massive project. It doesn't have to be something that's going to revolutionize healthcare. If we're being completely transparent, we're not going to do that, especially as an F one or an F two. But if there's something that we can create and implement that will either make a patient's life better, make a doctor's life better, make a nurse's life better, make the cleaner's life better or just improve any sort of patient outcomes. It could be a financial improvement. Anything that causes any sort of improvement towards anyone in a healthcare setting that can be AQ I. But the important thing to remember is if we can't measure that, then it can't be AQ I. So why are qis important? So I've got, I've picked three areas that I'm gonna try and stress to you guys of why they are important. So number one is professional bodies. Almost every single professional body within healthcare has some sort of commitment or requirement for QIS the GMC recommends that all doctors de demonstrate an involvement in Q I at least once a year, which is I'm sure many of you have never heard of that. As IM GS, we might not always enter formal training programs. We will be required to do appraisals almost annually. And in those appraisals, you're expected to show involvement in AQ I um I've also got some other definitions here, um and other statements from different Royal colleges and academies of why qi is important to them. So that's number one, why it's important. Number two, if you do get into a foundation um program or a standalone fy two to complete and successfully pass your A RCP, you have to um complete, manage, analyze and present AQ I project by the end of your F two year. Now, the A RCP is the annual review of competency progression. If you've not completed AQ I in that standalone fy two, you will not successfully pass that FY two and you will be expected to stay on for longer. Um I think some of you guys will be working at sho level without being in a formal fy two program. My personal recommendation is that you should be aware of what your peers requirements are and trying to at least create a level footing. So I would tell every I MG try your best to get involved if not create your own Q IP. Within the 1st 18 months of working in the NHS as a trainee, you guys are in a really, really, really good position to identify things in practice that frustrate you um and try to improve them. I think I've got the definition here, which is uh what this quote that doc junior doctors are the eyes and ears and it is absolutely the truth. Um We will notice problems before they become known to management in our seniors. Um And hopefully we can try and implement things to change them. And the third reason why Qis are important and arguably the most important to everyone listening to this is specialty training. Now, Q I PS hold large scoring points and almost all competitive specialty training applications. Now, I'm sure all of you guys watching it have certain aspirations. Whether you wanna go into internal medicine or surgery, it might be pediatrics or anesthetics. All of those specialties have a large amount of weight put on Q I PS. When you're applying, I can say with almost utmost confidence if you've not completed AQ IP, your application will not be successful when you're applying for specialty training, especially as specialty training, numbers become more competitive. Now, there are some specialties that don't require Q I PS. For example, some of you watching this may be aware, general practice GP, you just need to sit in exam. However, within your first two years of GP, you are required to complete AQ IP. So it's still really, really important. Um even if you do manage to get into specialty training, you will not be able to become a consultant through the formal training pathways without completing your Q IP. All right. So I've given you a lot of information very, very quickly, but just to quickly recap that um AQ IP is a systematic approach to making changes in the healthcare environment leading to better patient outcomes and enhanced professional development. It's really, really important for us IM GS to be aware of it because if you are in a form of fy two standalone, it's required for your SA RCP. If you are applying for specialty training, it will absolutely boost your application. And if you're doing neither of those, you need to be involved in it for your appraisal. So, um as I said, it's basically required for any form of career progression. Now, some of you guys might uh still be looking for jobs uh and applying for jobs and going through interviews and things like that. And I'm very happy that you've attended this talk because it's also a very, very common interview question about Qis your involvement in Qis and just to understand that you understand what AQ I is. So this next slide hopefully will be um helpful in terms of understanding the difference between AQ I and an audit and, and, and research. Now, um I do apologize if anyone in the chat is asking any questions or anything because I can't actually see it. Um But we will just go ahead to that next slide. I promise at the end, I'll, I've got loads of time to um to take any questions and hopefully answer anything that you guys might have. So, um an audit, what is an audit? What are we trying to figure out with an audit? Now, in summary, with an audit, we're asking the question of, are we meeting a required standard? What does that mean? That means that we have a national guideline or a trust guideline? But we have a ac a criteria and we are assessing whether our hospital or our department or our ward is actually meeting that required standard. It will then produce a percentage, for example, 70% of cases are meeting that standard, but there's no improvement there, there's no um project or thing to implement to improve that. That's all an audit is, it's just data collection um to assess whether we're meeting a standard. Research. On the other hand, I'm sure you guys are well aware of what research is, but we're asking the question of, can we discover more knowledge with the potential to improve quality of care? This is a definition for healthcare but obviously, um research can be defined slightly differently in other settings. Whereas AQ I, we're asking the question of, can we improve the quality of care actually being delivered? OK. So hopefully that clearly sets the difference between what AQ I is versus what an A is an audit? Are we meeting the standard? Yes, good. No, it doesn't matter with AQ I. Are we meeting the required standard? Can we make it better if we can make it better? How that's our project? The the project is the, how as I said in an audit, it's against a predefined standard. For example, it could be nice guidelines or national guidelines, it could be hospital and local guidelines. Um and the amount of data you need for an audit is, is, is not that much, but it's just enough that you can accurately assess and represent practice. Whereas you know, with research, you need to produce um much, a lot more data and demonstrate statistical significance and you need a large, large volume of data. Whereas um with a QR you actually just need enough data to inform your next improvement cycle. And what does that mean? You need just enough data that you can actually assess whether this thing is a problem or not and then be able to compare that later on once you've implemented your whatever you decide to implement, to, to, to, to produce that improvement. How long do all of these take? It's variable on average, I'd say in a it takes about three months. Um And the only reason it takes about three months is because you have to be able to make sure that you're representing practice. What does that mean? For example, if I'm assessing how many patients receive aspirin within 24 hours of having an M II, can't just do that in one day because for example, all the patients who had an M I on that one day might have been seen by one doctor and that's not an accurate representation of how the hospital is performing because there may be 12 cardiologists who will perform things slightly different. So you need a longer time period. Whereas with AQ I, it can be a rapid test and that can be hours, days or weeks. So you'll find that most Q I projects to be completed are done within um a few weeks um to months and research obviously takes a, a very, very long time. So just to further embed into your head, the difference between an audit and AQ I, these are examples of audits patients with previous M I should be prescribed aspirin unless contraindicated. Nothing within that sentence is trying to improve the number of patients being prescribed aspirin. All we're doing is comparing ha have they been prescribed aspirin patients with chronic asthma should be assessed every 12 months. Again, these are yes or no type questions. Are the patients being assessed every 12 months? Yes, good. No bad. But there's no um kind of thing trying to improve the number of patients being assessed every 12 months. And that's all an audit does. And these are just a few more examples here. Examples of qis however, or something like this to improve junior doctor confidence in prescribing electrolyte replacement by 50% in the next six months immediately. You can see we're trying to improve something. Another example is 60% of asthmatic patients aged above 35 years with symptoms of CO PD to have spiro spirometry performed within the GP practice by November 26 you can see very, very quickly that these are incredibly specific um targets that we are putting in place and they're measured, they're achievable, they're realistic and they're timely. And you can find that within all of these examples um for these aims within Q I. So the first step to performing AQ I is identifying a problem now that might be easier said than done because sometimes we can see things within a healthcare setting. We don't know how to articulate, articulate the problem. So that's the second step, we have to think about how can we articulate the problem. The third part is, is really, really difficult actually because there's so many different cogs and teams and people involved in a healthcare setting that we need to understand exactly why that's a problem. Sometimes it might appear to be a problem to us, but it's not a problem to everyone else. And once we've done those three steps, we can then create an aim and the aim is something which is gonna be specific, measured, achievable, realistic and timely, how do we know that you're picking the right project? Well, the first thing is, do you care about it? Is this problem something that you actually care about? If the answer is no, please don't do it. Q I projects are quite boring as they are. If you don't care about it, you're gonna really, really struggle. The second thing is, can you measure it? Is there a method for measuring the data. If you can't, you can't be AQ I, you absolutely can't do it because you can't prove that there's any sort of improvement. Will you have enough data points? We'll get into this a bit more detail later on. But you need to have enough statistical data points to prove change. If you don't have enough data points, it can't be AQ I unfortunately, and the fourth thing is, is, is not as important but is important is will other people care about it? And the reason why you want to assess if other people care about it is because if other people care about it, they're more likely to actually implement the changes which you are trying to um put forth. So as I said, pick something that frustrates you. That's a really good motivator to change it. If there's been an incident in the hospital and you think of a solution that can fix it. That's a fantastic um kind of a fanta, a fantastic base for you Q I um lessons learned sessions. These are reflective sessions that we sometimes have in the hospital. If there's ever been one of those, it could also be um a good foundation for AQ I. And the fourth thing is you can actually use an audit to act as the base for your Q I project. For example, if we were to say the audit is 70% the audit outcome was 70% of patients are prescribed aspirin within 24 hours. We might ask, why is that not 95%? Ok. Let's try. Let's see what we can do to improve that number, implement a change reaudit. And now that's AQ I, so you'll see a lot of qis start on the back of a previous audit. I hope that makes sense. And this is the last thing that you and, and a mistake that a lot of people um fall into is we've got to think about problems, not solutions. Sometimes people think, oh, I can make that better by doing this. That's not the right way of going about it. We gotta think about the problem first, assess the problem, understand it and then think about how we can make a decision. Once we know a problem, let's not get tunnel vision. Why is it a problem? Is it a problem? Just because you don't like it? That's probably not a good enough reason. Is it a problem for the patients? Better reason? A problem for your team members? Very good reason. A problem for the wider organization. That's a fantastic reason. It's important to understand why it's a problem. Um And not just something that frustrates you. There's a lot of things in healthcare that frustrate me that I don't want to do, but they're not problems, they're actually necessities. So what is your problem? Now? I would usually, if we had had a host, I would have liked to ask you guys if you guys can think of any problems that um that you may or may not have. Um But I don't think we have a host at the moment. So we will, we'll leave that now. But if you can just for those watching at home, just think about any type of problem and it might hopefully help um in the next few slides, if you don't, I I've got some examples coming up. So the underlying principle, this is Deming's system of profound knowledge. Now, Deming's system of profound knowledge is he came up with four key elements that you must consider. If you wanna make a change or I should say a successful change um in our sessions that we had in the hospital, we spent about an hour, an hour and a half, just on these four key principles. I'm gonna try to do it in two minutes. So um just bear with me in order to change a process or a system, you need to understand, you need to have an appreciation of the system, you need to understand how that system works and, and the function of it. You also, and this is for absolutely anything you need to understand the human side of change. What's the human side of change? The human side of change is understanding that humans naturally don't like change. Humans naturally might not follow it. You're gonna have those people who are a bit keen and wanna jump on any sort of improvement or any change you're making, but there's always gonna be some resistance building knowledge that goes back to understanding that the, the, the systems in place and trying to build more knowledge to try and I er implement the best form of improvement. And the last thing is understanding variation, we're gonna talk about variation a lot more in a second. But understanding variation is basically understanding that things change for reasons out of our control. Um And there will always be variation in anything that is as chaotic as, as, as the healthcare system. Now, you need to understand all those four elements. Um As I said, there is a lot more depth to this. But um if you just remember those 44 things, hopefully that will help. Let me just quickly check my phone. OK? So I've just seen that we had a question. I will answer all these questions towards the end. I, if that is OK. All right. So example, problems. Um These are just some quick examples that I came up with so outlier patients not being seen every day. Now, for those of you who haven't worked in the NHS, um there are a lot of patients who are in the NHS, they came in for a medical reason, they've got better, but their social situation is not safe so they can't go home. So a lot of them are uh they're medically optimized. We're ready for them to go home. But their home situation is not safe. So sometimes we'll move them to another ward and they will now be considered outlier patients. Unfortunately, sometimes those outlier patients are forgotten about and the medical team is so busy on their wards. No one reviews them because we know that medically they're a lot, lot better, but they still should be receiving, um, daily reviews. That's a problem. Another problem is poor communication between phlebotomy and ward doctors. Now, anyone who's worked in the NHS knows that this is absolutely one of the most annoying things in the world. You request 10 patients for morning bloods. You come in, you complete your ward round and you're told that the phlebotomist never came and none of those bloods were taken and now it's 2 p.m. and you need to take 10 bloods for 10 patients and you're not gonna get the results back until 5 p.m. and it, it's just chaos and discharge summaries, et cetera. So um these are just example problems um and things that we could possibly do something to improve. So once we've identified that problem, we need to create a smart aim, a smart aim. You may have heard me talking earlier about what those examples of Q IP, the smart aim is your target. What do you want to achieve in your Q IP? And it must achieve these five things. It must be specific, it must be measurable, it must be achievable. It must be realistic and it must be timely. We'll go into a bit more detail specific. It means keeping the scope and scale manageable. You're only a doctor, you might have a team of you guys doing this Q IP, but there's no way you can assess the whole hospital. So that's not realistic. You gotta pick a single aspect of care, it might be trauma and orthopedics and you've got to define clearly which area within that, that you want to improve measurable. You must have a numerical value that you can measure. For example, a percentage or an average score or the number of times that this has occurred, you have to be able to measure that. If you can't measure it, it can't be a cure achievable and realistic is what you're trying to achieve actually possible. Is it realistic? Can we realistically improve, say 95% compliance of people taking aspirin? Is that achievable or realistic? You might be a bit ambitious, but we don't need to be overly ambitious. We need to think about making changes that can actually be realistic. And the last thing is timely. What date do you think you can make that change by? You might only have a 12 month contract, you might only be in a department for four months. You've got to think about that. You don't want to be doing AQ I for 12 months. There's absolutely no need, think about the time frame in which you want to achieve your goal and put that within your smart aim. So, examples of good smart aims are these, I've mentioned some of them before but to improve junior doctor confidence in prescribing electrolyte replacement by 50% in the next six months. It's specific, it's measured, it's achievable and realistic and it's timely. It's got six months in there. Ri would always recommend for everyone to literally write down S MA RT and make sure you tick all of those boxes. When you're thinking of your smart aim, we'll get, we'll mention it towards the end of the presentation. But without a smart aim, your Q I will not be valid um and it will not be accepted. So um there's another 1 60% of asthmatic patients aged above 35 years with symptoms of COPD to have spirometry performed within the GP practice by November 2016. It's incredibly specific. It's measured, it's achievable and realistic and it's timely and um once and it, it, it, it has these pretexts of things that are symptoms of CO PD. Now, if we were just a 60% of asthmatic patients above 35 years of age, that's a much larger pool than the 60% that only have symptoms of spirometer of CO PD. So we, we're trying to narrow it down as much as possible to make it achievable and there's just a few more that you guys could have a quick read of now, going back to understanding the why, understanding why it's a problem. Let me just get to my notes one second. All right. So if you don't understand that, a s if you don't understand how a system functions, you can't fix it. For example, we've got these three images here. We have a Ferrari here which might have a fantastic engine. We have formula one cars which have some of the, the best tires. And we have um a range rover which has a fantastic body. If we were to put all of these three things together, that car would be absolutely awful because these three things have been designed with different purposes. So if each part of the system is considered separately and it is made to operate as efficiently as possible, then the system as a whole will not operate effectively. And this is really, really important within healthcare because there's a million and one different systems going on different people involved in different settings. And it's important to understand how they all come into place when trying to change something. And if we do that, then hopefully we can implement something efficiently and effectively. If we don't, we can still try to implement it, but it probably just won't be very good. Um This is also just talking about why this previous slide is important and there's a lot of inefficiency and waste, uh waste of time, waste of money, waste of resources. Uh of people within healthcare um because they're doing things and they're not doing it properly. Um You can see that with, with, with, with, with many, many different examples. Um And if we did understand our processes, we could actually save a lot of money and a lot of time. So variation and analysis in Q I so analysis in Q I um relies on trends and these trends um are really, really important in order to identify what is the baseline, what is normal. Um It's aim is to influence trends. Oh sorry, the aim of AQ I is to influence the trends and identify chan changes outside of normal um and make that the new norm. So how do we display variation? We display variation through? Um Well, let me hold on that. How do we display variation? We can display it in a botch up. For example, this bar chart says the number of complaints in a general hospital year by year, in year one, we received 89 complaints. Whereas in year two, we also received a, you know, complaint. So you could argue and say, um you know, we we're doing quite well. Um There there's not been a significant change, but if we were to display this information differently, you suddenly see the data completely differently. So here is 89 complaints spread over 12 months. Something's happened here. There's been a massive change. You can see that consist, there have been quite a regular number of complaints from January to January. But then in February, something massive, um, has happened. So you can do the baseline complaints, 16 complaints per month. Um Whereas in February, something quite strange has happened and then it's gone back to the new baseline. This is what we talk about when we talk about variation because there's always gonna be abnormal patterns and we've got to take that into consideration because we cannot work based on those abnormal patterns. There may have been a reason what happened in February was the hospital and the staff was there a large influx of patients, what what changed in February to increase the number of complaints. So going back to the, the idea of making AQ I before you do any sort of implementation to change, you must collect baseline data. So that baseline data is what we collect at the beginning to assess how we're performing before we make any change. Um In order to deem that, that baseline data is, is accurate, you need at least eight points. OK? So we've got eight points over a time frame that is self defined. So we can self define that whether it be a week or daily or, or whatever, but we need at least eight points. We need to jot them down and then we can think about what improvement we're we're implementing, give that improvement some time because it's not, the improvements are gonna be seen instantaneously. So give it a bit of time for people to accept, for people to be aware of what you guys have changed and then for people to start acting on what you've changed and then you need to reassess for AQ I result to be significant, there needs to be a further six points above or below your previous um baseline. So six is what is considered statistically significant. If you have that shift of six points, you can now say that your Q I was statistically significant. Now, this is a really important thing. If you've done AQ I and tried to implement something that didn't cause any improvement, it's still AQ IP. It might not be something that the hospital takes forward and implement in a long term, but it's still AQ IP, not all Q I PS are going to be successful. Now run charts are the gold standard for Q I PS. If you want a successful Q IP to be accepted, it has to be demonstrated as on a run chart. Um And I hope you guys can appreciate why um with, with this example of, of a, of a bar chart. So as I said, one shot, we collect data over time, regular but small samples and it allows the appreciation for natural variation. You need to collect baseline data before any change to identify what is natural. And it, it says, imagine if we had just audited this data in two months, how do we know, we hadn't by chance got a really good month or a really bad month. Ok. So we've created our pro not created, we've identified our problem and we've calculated enough data to demonstrate what our baseline is now. And we, and we've thought about what we're going to implement, to um to improve this problem. We, we've done quite a lot but we need people to be engaged. We need people to actually support our project. We can't do this alone and that's where we have to think about engaging our stakeholders. Now, stakeholders, are anyone with an interest or anyone who could be affected by your Q I now in a hospital, stakeholders could be absolutely anyone but the you have to recognize who these stakeholders are and, and how they can support you. So from a medical team could be consultants, your supervisors, other other F one and F two doctors, depending on what your project is, your stakeholders are gonna be slightly different. But it's important to not forget that they, there are nonclinical stakeholders and these people hold a lot of power. Um So for example, here, it could be site managers, it could be uh the ward clerk who say assesses all the discharge summaries once they've gone through nurses on the ward, physios, ot social workers, pharmacists, uh families, parents, all of these type of people caner often be um support and, and be stakeholders within your, your Q I PS. So it's really important to think about those and, and let them know, let them know. And if you get them on your side, your Q IP is much, much more likely to be, to be successful. And this is another thing that again, coming from Bulgaria, we might not be aware of, but uh in, in the, in the NHS, it really is a multidisciplinary team and everyone really does have a significant role. So um being aware of all those people trying to get them in involved in your project, um will, will, will not only make your pro project uh more likely to be successful, it will make your life a whole lot easier. All right. So we're, we've kind of whizzed through all of that. We've almost got towards the end. So I do appreciate you guys for, for staying through this, but just to, for an end, um I just wanna remind you guys that if you can't measure it, um It can't be AQ I because without data, you're just another person with an opinion and it's really, really, really important to um to remember that. Now, as I said, this was a lot of information. We've gone through it very, very fast, but you're not on your own. Um Most hospitals will have um things like this which are quality improvement and audit teams. This is my own hospital. I hope you can see this, but this is their registration form. And when you're actually um completing this registration form, you talk about how much support you need and they can help you with things such as creating the runs shot or the determining the statistical significance and, and all those type of things. So it actually asks you on one of the pages, how much support do you need here? Now, in all you have that I've done, I've always requested for support. Uh um but you're not alone qis, as I said in the beginning, they are really, really, really um important thing within the NHS, whether you agree or not, that's not for us to decide, it's just the reality of the situation and because they, they help, they hold so much weight. Um you know, there, there are research and audit teams in place um which will um support you guys um with that project. So final few bits, if you want a successful er Q I project as per the um A RCP criteria, it must have a smart aim, it must be measured and you must use a run out. Those three things have to be displayed. Um It will not be accepted if your project is seeking to see if you're meeting a standard. The reason why is because that would be an audit, not AQ I these audits however, can provide the baseline measurement for an improvement which you want to implement. Um How do you prove that you successfully completed AQ I project? So anyone can say, oh yeah, in my hospital uh II did this Q I project. Um How do you prove that? That's actually the case. So there is an assessment tool called the Q IP at it pretty much is a form that looks like this. Um And once you've completed your Q I, it's important to just get that form, make sure it's signed by all the relevant people. These are gonna be your supervisors, some of the people from the research teams that helped you out and, and it just has a brief explanation of your Q I um And that can stay with you for life. So whenever you're applying for other future jobs or, or other specialty training posts, that is a form of proof. Um So our organization tips Q I which is um a Northwest organization. It's APL organization. They have a lot of guides on their website to feel free to, to join. Let me just see. I'm getting a message here. Sorry. So, um on, on our website, we have Q I templates, we've got examples of project ideas. Um We've got a lot of information and more information on run charts if that's something that you guys are unsure of. We also offer one on one coaching sessions if you're deciding to do AQ I and you're a bit lost. Let us know, pop us a email, the emails and all the information's on the website and we've got registrars who work with us who can give you a one hour time slot and support your Q I project. And we also have an annual regional foundation uh Q I conference. Now, this is absolutely fantastic. If you have completed AAA Q IP, um you can apply to join that conference and present your poster. Now, between me and you guys any completed Q I will pretty much get accepted. So um if you were to be able to get that on a national conference that also holds a large number of points for your specialty applications. Um There are prizes and things like that um which are also um nice incentives. So well, hopefully, now go to any questions. As I said, it was a lot of information. I really, really do hope that it was clear to some extent, this is just the baseline. I hope you guys are leaving this talk today. Now have an idea of what AQ I is, have a brief idea of how to pick a good project and, and, and at least the baby steps of where to go from here. Um I'm happy to do um any other talks at any point, as I said, we have this team here tips Q I, we do help out um If you guys wanna contact me directly. Um You, I'm, I'm more than happy to do that. I'll put my details in the chat. Um And yeah, we'll just take you over to questions. Now, let me just see if I can um figure how to see those. Now, stop sharing. All right, let's see. Is there any questions? Which national conference is this, please? So this is our own tips. Q I um National Conference. We, we, we, we, we are the ones that organize it. Um And again, there's more information on that, on our website. The dates haven't been finalized yet. It should be about July this year. Um But if you keep an eye on that, you can apply and, and, and submit your, your Q I probably will be accepted and, and that will, that will give you um some fantastic points when thinking about your, your specialty training. Um Was this question, is there any Q IP at equivalent form that can or should be filled out when AQ I is done outside of the EU? Um It's a good question. Um I don't actually know the answer to that. Um I do apologize. Um I think to be completely transparent as long as you've got some sort of proof, um Most people will accept that the Q IP at is, is, is, is, is nationally recognized and it makes it easier for you guys. Um But if you're able to, you know, to, to, to actually just prove, if you can get the poster, prove your sign uh your statistical significance and explain that, that, that, that should be more than enough. And I can't really see anyone questioning that. Um How short of a time frame could you realistically do? AQ IP even if it's a simple idea to improve something, could it be done within a month? Uh Yousef. Yes. Yes, it can be done within a month. I've seen QR S done within a month. I personally always recommend people to try to aim within three months. Um A rotation tends to last four months. So if you aim with three months plus all the um all the the nonpredictable, hopefully you can get it done within four months. If you're really, really eager, you can do it within a month. But as you said, it depends on the idea. Um Any other questions, there's more questions at the top. Let's see. Do Q I PS or audits need to be done individually or can it be done in a small group? Um Good question. Yeah, they can be done in a group. Um I would always recommend um getting two or three of you guys involved, spreads out the workload. You guys will all be um you'll all receive the same accreditation for it. So, um you can spread it out over a, over a number of doctors um and get everyone involved and that will help with, you know, the data collection side of it. And um so absolutely, it can be done um with a group and, and, and it's commonly done within a group. Um You can do, is there any other questions. Have I missed anything? Can we approach hospitals to carry out audits or Q I PS as external candidates or would we have to work there? Great, great, great question. So, um it really depends um in the issue is um I it's uh it, it, it's patient confidentiality. A lot of um QR s might involve you assessing patient data. So if you are not registered to the hospital, they might need to do a background check if you've got a DBS or something along those lines and you've got a supervisor who will support you. Um They oftentimes they will be ok with it. II would say the best way of getting involved with an audit or Q I would be when you're on your attachments. Um Ask around most of the F ones, most of the F twos, the senior registrars will be involved with qis to some extent and hopefully they can give you the opportunity to support them. Um Not all qis involve information which is, is going to affect um patient confidentiality. But if you're already in the hospital doing an attachment, you've already had your background check secured and everything you should be ready to go. Um So that would be my recommendation. Um If, if you, if you've not got a job at the moment, um If you do have a job, just ask around in the mess, ask people, trust me, everyone's getting involved in these. Um And everyone wants help because we've got so much other stuff on our plates. Um It's always nice to have an extra hand helping you with your P I. Um Could you explain collecting eight points to establish a baseline and then six points above or below the baseline for AQ I to be significantly significant. First thing well done because you've, you've quoted me verbatim. Um So what it means is when you are trying to assess that something is normal, you need to assess that over at least a minimum of eight um markers. Uh you define that. So for example, if I was to say patients uh who are getting aspirin within 24 hours of having an M I, um that would need to be done over eight days, for example, so we can have some sort of variation and see if there's any change. Ideally, you'd do it over eight weeks or something a bit longer, but it's not really realistic in terms of um the time that we have a, a as junior clinicians, but you just need enough data to be able to say, well, look, we, we've got this sample size, we've now changed this and then using the exact same time scale. So if you've, you've checked everyone over a day, you need to make sure that you're checking it over a day again. So for example, if um on in that first week um that you've, you've, you've checked the patients who've had mis on day one, you had five patients with mis four of them were prescribed aspirin on the second day. Uh One on the third day, there was 10 patients and three of them were prescribed as aspirin. And you've got this nice little trend, find what the mean is. You'll find what the average is. The average is. 50% of patients are receiving aspirin. Now you are ju have come up with a great idea to put an alert on the system that anyone that comes in with a suspected M I will alert the doctors to prescribe aspirin. And after that, you've now checked over the next week after that alert has been implemented. And again, there's, there's variation, but the average has gone up to 70% over six days. So it can't just be 70% over one day. It has to have gone up over a selected number of, of, of points to. So you can make sure that the average is actually increased, not just in that one day. I hope, I hope that made sense. Um Can I name this? AQ I A after realizing a need for quality improvement from an audit which was served in the hospital management within? Absolutely. So yeah, you can make Q IP O over an audit. Um And I would honestly recommend that's the best way of doing it because if there's an audit which has already been completed and you think there's something that you can do to improve half the work is already done for you. Um Half the work is already done for you. So um that I think that that's, that's probably the best way in terms of trying to do it in a, in a concise way. Speak to your, your consultants. Um Consultants are aware of all the audits that are going on, but management is constantly telling them if the department needs to improve in some area. So they will already have an idea in the back of their mind of what can and can't be done. Um But absolutely, if there's an audit that's already been done, even if it's a few months ago, um definitely you, you, you can, you can do something about that. Um Can you give any advice as to how to maximize a clinical attachment apart from asking people in department about doing Q I PS, et cetera? Um Good question Yussef. So, um when I, when I graduated, I was, I was involved in two attachments and I don't think I maximize them as much as I possibly could. Um What would I do differently? I think your goal. Um And what I would tell people now is the goal is to try and position yourself in a way that you can walk into the hospital the next day and do that task completely. It's one thing shadowing and you know, oh, this doctor is doing this and doing that. But think about what steps they're doing in their day. So that God willing, if you do get an opportunity or you do get a contract soon, you can take their steps and, and literally um perform that job. So um understand how they communicate. I think the biggest thing that separates IM GS versus, versus UK graduates is, is our ability to communicate. Master. Please, please please master the sbar master how you can communicate to uh um critically ill patients and how you can um articulate that to other staff if you can work on your communication and just understand the actual sequence of a normal ward day, understand the sequence of how an on call works. Um That will probably be the, the, the best way to maximize your, your clinical attachment. I hope, I hope that helps. All right guys. Um I think that is everything. I'm just going to plug my Instagram in there. If anyone wants to message me at any point, I II try my best to help um as many students as I can. Um If I don't get back to you in a few days, I promise I will sometimes it's I'm just a bit slow getting back, but I get back to everyone. Do let me know if there's any questions or anything I can help with. Keep an eye on the tips Q I website if you guys have any other questions. Um I hope if you could please complete the feedback for me. It does help us out a lot. Um And thank you so much for attending this talk. Bye.